The patient will likely complain of scrotal pain and swelling, quite often gradual in onset rather than acute. It may begin with flank pain that migrates to the scrotum. The patient may also complain of urinary symptoms such as dysuria, urinary frequency, urgency, or incontinence of urine. The patient might also complain of urethral discharge. A careful history should include the possibility of traumatic injury or injury from repetitive activities such as sports, sexual history including history of prior sexually transmitted disease exposures, and past medical history including problems associated with the genitourinary tract such as prior urinary tract infection, prostatitis, or surgical procedures.

A physical exam will likely reveal swelling of the scrotum, and palpation of the scrotum will likely reveal tenderness of the scrotum, usually unilaterally but in some cases bilaterally. Tenderness to palpation of the epididymis along the posterior and superior aspect of the testis is the hallmark of epididymitis. Tenderness upon palpation of the testis itself may indicate the possibility of epididymo-orchitis or orchitis. The skin overlying the scrotum may appear warm, erythematous, inflamed, and indurated as a result of infection. Tender inguinal adenopathy may be present as well.  Physical examination of the penis may demonstrate a urethral discharge. Digital rectal examination may demonstrate tenderness upon palpation of the prostate gland. These findings, while not necessarily indicative of epididymitis itself, might be present in infections of the male genitourinary tract.

Evaluation of the male patient with scrotal pain should begin with urinalysis. Though nonspecific, the presence of red blood cells and white blood cells in the urine may indicate an acute infectious or inflammatory condition. Urine should be cultured to determine the causative agent in cases associated with urinary tract infection. A urethral swab is indicated in cases where the sexually transmitted disease is considered likely given the patient's sexual history. The radiographic evaluation includes ultrasonography with attention not only to the anatomic structure but also to assess vascular flow to the testis. Ultrasonography can demonstrate inflammation of the epididymis and testis in cases of epididymitis and epididymo-orchitis. Computerized tomography also may be of use in cases where the patient has flank pain and urinary symptoms associated with an acute genitourinary problem such as ureterolithiasis.[6][7][8]

Of utmost importance is ruling out the possibility of a testicular torsion as a cause of the scrotal pain. While epididymitis tends to occur rather gradually, the pain associated with testicular torsion often occurs very abruptly. History alone, however, may not be sufficiently clear to exclude the possibility of testicular torsion as a result of acute scrotal pain without the aid of emergent urological consultation and ultrasonography.[9]

Treatment of epididymitis is based upon identification of the causative organism, though presumptive treatment may be initiated based upon the prevalence of the most typical agents (C. trachomatis, N. gonorrhea, E. coli).  For suspected sexually transmitted cases, ceftriaxone along with doxycycline is recommended although azithromycin can be used as an alternative.  Fluoroquinolones may be used in older patients where an enteric organism is suspected or likely. Pain and swelling can be dramatically reduced in many cases by using ice.[10][11][12]

• Epididymal congestion following vasectomy

• Hydrocele

• Orchitis

• Referred or radicular pain

• Scrotal trauma

• Spermatocele

• Testicular trauma

• Testicular seminoma

• Tunica vaginalis tumour

• Urinary tract infection

Patients with epididymitis caused by sexually transmitted disease should refrain from sexual intercourse until asymptomatic, should consider safe sex practices to reduce the chance of re-infection, and should refer sexual contacts to their primary care physician or to their local health department for evaluation and treatment. Patients with epididymitis caused by urinary tract infection should be encouraged to drink plenty of fluids to flush the genitourinary tract, should be advised to take the entire course of antibiotic as prescribed, and should follow up with both their primary care physician and with a urologist for further evaluation and management. When the clinician entertains the possibility of sexual abuse, he or she should contact local authorities, child protective services, or other social service agencies based upon laws, policies, and procedures of that jurisdiction. Epididymitis caused by repetitive activity is treated symptomatically with rest, anti-inflammatory medications, scrotal support, and close primary care follow-up.

Epididymitis is a frequent presentation to the emergency department. However, the diagnosis can often be confused with testicular torsion, which is a surgical emergency. The emergency department physician, nurse practitioner and internist who encounter patients with testicular pain should consult with a urologist if there is any doubt about the diagnosis.

Patients with epididymitis should be educated about safe sex practice. In addition, these patients should be encouraged to drink plenty of fluids to flush the genitourinary tract, and be compliant with the antibiotic therapy

The outcomes for most men with epididymitis are excellent, but relapses may occur in patients who are not compliant with therapy.[13]